


MRN 2054076

by smleeish



Category: Overwatch (Video Game)
Genre: Blindness, Cardiopulmonary Resuscitation, Depression, Documentation, Epistolary, Growing Old Together, Healthy Relationships, Hospitalization, Hurt/Comfort, Injury Recovery, M/M, Medical Conditions, Medical Procedures, Medical Professionals, Old Age, Post-Canon, Post-Traumatic Stress Disorder - PTSD, Psychologists & Psychiatrists, Realistic, Sex (mentioned), Sexuality, Suicidal Thoughts, stroke
Language: English
Status: In-Progress
Published: 2019-08-22
Updated: 2020-04-07
Packaged: 2020-09-23 19:37:51
Rating: Teen And Up Audiences
Warnings: No Archive Warnings Apply
Chapters: 8
Words: 10,722
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/20345593
Author URL: https://archiveofourown.org/users/smleeish/pseuds/smleeish
Summary: CURRENT FUNCTIONAL STATUS:Stable, with patient's LOC remaining in stupor and abnormal. Mr. Morrison is not currently oriented to date or location. He is a 1-person assist to sit, 2-person assist to overhead lift. He demonstrates dysphagia, which has improved, but has not yet demonstrated self-feeding capacity and may require insertion of a PEG tube, query at next consult.Time and old age catches up with Jack.





	1. DISCHARGE 1_16-10-2083

**Author's Note:**

> This is a work of fiction. Any inaccuracies are due to inadequate knowledge on my end or creative license. Any similarities to real life cases is unintentional and merely a result of too much time staring at a computer screen and too much tangential curiosity.

DATE OF DICTATION: October 16th, 2083

NAME: MORRISON, John F.  
AGE: 62  
DOB: XX-XX-2021  
SEX: M  
DATE OF ADMISSION: September 18th, 2083  
TREATING UNIT(S): STRK & NEUROLOGY

*DO NOT ANNOUNCE THE PATIENT*  
Copies of this report have been requested by multiple parties without approved authorization. Please ensure that ONLY the patient's designated physician, Dr. Angela Zeigler, may receive a copy of this dictation for the patient's medical records.

MOST RESPONSIBLE DIAGNOSIS:  
Left MCA territory infarct with multiple embolic showers.

COMORBIDITIES:  
1\. Lifetime smoker of at least 40+ pack years,  
2\. COPD and emphysema  
3\. Alcohol use disorder  
4\. Glaucoma — visual impairments more distinct in the right eye, but legally blind  
5\. Migraines with aura

PRE-ADMISSION:  
1\. Atrial fibrillation  
2\. Hypertension — 180/90 mmHg  
3\. Delirium

POST-ADMISSION:  
1\. Atrial fibrillation  
2\. Ventricular hypertrophy  
3\. Dysphagia with intubation — puree diet n.p.o

MEDICATIONS:  
Metaprolol — 100 mg I.V. q.d.  
Heparin — 5000 units I.V. initially; 40,000 I.V. q.h.d. (to maintain post November 6th, 2083 indefinitely)

CODE STATUS:  
Full code (Note: DNR 2 — comfort care arrest only, as reported in record, however, there is questionable competency of the request, thus full code is instated until confirmation by the patient and his family. See below for details)

CONSULTING PHYSICIANS:  
Dr. Stefany Huang, Stroke  
Dr. Yuriy Burstein, Neurology  
Dr. Diana Cooke, Rehabilitation

CURRENT FUNCTIONAL STATUS:  
Stable, with patient's LOC remaining in stupor and abnormal. Mr. Morrison is not currently oriented to date or location. He is 1-person assist to sit, 2-person assist to overhead lift. He has dysphagia, which has improved, but has not yet demonstrated self-feeding capacity and required insertion of a PEG tube. Given his progress, we will query removal of the tube and transition to solid foods at next consult.

DISCHARGE STATUS:  
Extended care.

TREATMENT/COURSE THROUGH HOSPITAL:  
Mr. Morrison is a 62 year-old gentleman who was admitted to XXXX Hospital on September 18th, 2083, and presented with slurred speech, a flattened right nasolabial fold and right sided hemiparesis. He is a veteran, well-known to the public, and had retired from active duty several years ago for complex reasons, the least of which involved his physical and mental wellness. According to his partner, Mr. Morrison had complained of headaches for several days before he was found prone and unresponsive at a local grocery store where EMS was activated by staff. Upon arrival at the hospital, he was treated as a hot stroke and transferred to emergency. A CT head scan revealed a proximal MCA territory infarct with multiple embolic showers; MRI revealed hemorrhagic transformation on repeat scans. The EKG results revealed atrial fibrillation, suggesting a cardiopulmonary source of the emboli. His blood pressure also measured in at 180/90 mmHg, with no previous history of hypertension, so he was started on intravenous metoprolol 100 mg. Given the patient's history of intracranial hemorrhage due to severe head trauma sustained in 2070, as well as abnormal phlebotomy results suggestive of his participation in military research, he was found not to be a candidate for tPA administration and was ultimately anticoagulated conservatively with intravenous heparin and hypertonic saline to reduce intracranial pressure.

Mr. Morrison's hospitalization was unfortunately complex due to his extensive history of traumatic injuries, chronic smoking, and several in-hospital complications:

1\. Severe dysphagia — Mr. Morrison initially developed severe expressive aphasia and was started on a puree diet. Unfortunately, it became quite difficult for him to swallow, thus a gastrostomy tube was inserted to ensure he received regular feedings. He is n.p.o. until further assessment by the speech therapist, which we will query as soon as possible since the tube seems to cause him much discomfort.

2\. MRSA type infection — Although Mr. Morrison was compliant with staff, he often would be found removing is PEG tube, which has led to a staph infection at the site of the surgical opening. Test results revealed MRSA type bacteria which further complicated his health status and delayed treatment while an effective combination of antibiotics was investigated to clear the infection.

3\. Pneumonia and acute respiratory failure — Mr. Morrison acquired pneumonia of the klebsiella type, which resulted in an acute respiratory failure during his course. He was quickly treated with combination therapy (amikacin and meropenem) which was successful in clearing the infection, however, his cardiopulmonary status deteriorated rapidly post-treatment, most likely secondary to his COPD and deteriorated neurological status. He was resuscitated on a full code, however, this was apparently done before the treatment team were aware of Mr. Morrison's DNR status in his medical records. His partner has expressed concerns over the code status as, prior to this event, he was unaware of the patient's self-reported code status in record. Mr. Morrison's partner is listed as his advocate, dated back further than the most recent record, thus, in order to maximize the patient's best interests and safeguard against neglect, we will be clarifying Mr. Morrison's DNR status once his cognitive levels have improved, until which we will treat him as a full code as per his partner's wishes.

4\. Delirium — throughout the patient's stay in hospital, he demonstrated altered levels of consciousness, including hallucinations. He was reported by visitors to be calling for deceased family members and squadmates from his regiment in the military. The psychiatric team were consulted and performed a cognitive assessment, for which Mr. Morrison did not pass. He could not state the day or year, and was quite stressed over insisting his partner was deceased as well. He could not recognize the younger members amongst his visiting colleagues. Follow up with Psychology will be arranged for untreated trauma (see below).

5\. PTSD — Mr. Morrison has a separate record documenting his extensive history with PTSD. He has been reported to have refused therapy in the past, resulting in failure to thrive under prolonged hospitalizations. There has been at least one incident so far in hospital where Mr. Morrison experienced intense distress, dissociation, and persistent negative affirmations about himself. Please refer to records shared by Dr. Zeigler in case of any incidents of self-destructive behavior.

At the time of this dictation, Mr. Morrison's condition is stable. Mr. Morrison's partner and colleagues have expressed their desire to have him discharged home under their care, however, Mr. Morrison remains sub-optimal and we have discussed several options with the goal of optimizing recovery and eventual full discharge, which his partner has been reluctant, but agreeable to. Thus, we are awaiting his transfer to extended care for ongoing supervision and convalescence. Functionally, he is antigravity on the left side, but unfortunately maintains a dense right hemiplegia. At baseline, Mr. Morrison is reported to be highly active and fit for his age demographic. Despite developing chronic pulmonary dysfunction consequential to being a lifetime smoker, and a history of migraine headaches and alcohol abuse, he was otherwise found to be physically healthy prior to his stroke. Since identifying his hypertensive state, blood pressure has been maintained within acceptable levels as of last check, 130/80 mmHg. As this is my last day in the Stroke unit at XXXX Hospital, Mr. Morrison will be followed up by my colleagues, Dr. Guy Winch in hematology and Dr. Yuriy Burstein in Neurology. By the end of his stay in ICU, Mr. Morrison's delirium resolved enough for him to recognize his partner and friends, although LOC remains lethargic. Given Mr. Morrison's extraordinary recovery from a series of unfortunate events and his rapid stabilization thereafter, I am hopeful he will be a good candidate for rehabilitation based on his current prognosis. Once he is approved for removal of the feeding tube and back on a solid food diet, I will leave determination of his candidacy to Dr. Diana Cooke for further assessment of this. Psychology will continue to monitor and follow-up on Mr. Morrison's progress with the goal of counselling for his underlying conditions.

Thank you for involving me in the treatment of this patient. It has been an honor providing care for a veteran in his time of need. I wish him and his partner all the best in his recovery. Should you have any further inquiries, please do not hesitate to contact me.

Dr. Stefany Huang

**Notes for the Chapter:**

> Years worth of notes and unfinished ideas in various fandoms, and this is what my brain clings to after nearly three years of hibernation. (╯°□°)╯︵ ┻━┻
> 
> This'll be a short fic, but we'll see how long my brain can stay conscious enough to finish it, for as long as my heart bleeds for geriatric romance/hurt/comfort. UwU
> 
> Since there is quite a bit of terminology regurgitated here for realism, I'll post only the abbreviations and the really obscure wordy ones that might need more explanation. 
> 
> Terms:  
LOC - levels of consciousness  
MCA - mid cerebral artery  
COPD - chronic obstructive pulmonary disorder  
atrial fibrillation - abnormal heart rhythms  
dysphagia - swallowing difficulties  
Metoprolol - a common beta-blocker medication to lower heart rate and blood pressure.  
Heparin - an anticoagulant, helps prevent formation of blood clots (emboli)  
q.d. and q.h.d. - daily and nightly dosage, respectively  
DNR - do not resuscitate  
hemiparesis - weakness of one side of the body (versus hemiplegia, which is complete paralysis of one side)  
MRSA - methicillin-resistant Staphylococcus aureus, a type of antibiotic-resistant bacteria  
ICU - intensive care unit
> 
> *crawls back under the bed to sleep in my altar of incomplete works*


	2. CONSULT 1_27-10-2083

Inpatient Clinic Note

NAME: MORRISON, John F.  
AGE: 62  
DOB: XX-XX-2021  
SEX: M  
DATE OF SERVICE: October 27th, 2083  
CONSULTING SERVICES:   
Haematology  
Gastroenterology  
Cardiology  
CONSULT REQUESTED BY: XXXXX

*This report is provided in correspondence for the patient's ongoing care. Any blanks represent redacted information. Any discrepancies from the original document should be reported directly to the hospitalist.*

Please refer to the discharge transcript dictated on 16-10-2083 for a detailed account of the patient's medical history.

I saw Mr. Morrison today at his bedside in XXXX Extended Care facility along with his partner and a close friend, both of whom are his acting proxies. He was awake and alert when I arrived, which is a great improvement since I last saw him in the ICU, although he remains prone and does not have the core strength to maintain upright sitting. He typically requires 2 staff to assist him in mobilization, however his partner has been successfully acting as a 1-person assist in the interim. He maintains right-sided motor deficits with asymmetric smiling. His speech is slow and aphasic, but he was able to follow along with our conversation with good comprehension. While he is essentially non-fluent, I was able to understand simple confirmation answers from him even without his partner's assistance in interpreting. There was much improvement in his swallowing capacity, for which he has been working diligently with the speech therapist, so we will be arranging for Gastroenterology to remove his PEG tube as he transitions to a soft food diet.

Mr. Morrison's history of alcohol dependence and cigarette usage have implications on his liver, renal, and cardiopulmonary function, and the fact that he has not presented with any congestive organ diseases prior to his stroke besides typical degenerative function, is remarkable. Mr. Morrison affirms that he participated in alcohol reduction therapy 10+ years ago, however, he was evidently reluctant to bring up the topic of his adherence to the program since. I discussed the benefits of smoking cessation to which Mr. Morrison was open to making lifestyle changes. Although Mr. Morrison is not yet ready to contemplate harm reduction in regards to his dependence on alcohol intake, he does have a strong support system in place at home which I am optimistically assured will help facilitate him when the time comes.

As described in his previous transcripts, Mr. Morrison's blood workup has been consistently abnormal, including lipid profile, HbA1 and serum fibrinogen activity, throughout his hospitalization. One of the widely suggested causes has been the patient's previously known participation in classified military research, involving medical augmentations. Besides the questionable ethics of such medical practices in the last century, it must be acknowledged that our freedom to investigate and target these abnormalities is limited, even on the principles of beneficence. As long as we may rule out the patient's altered physiology as a possible pathological cause for his recent stroke, then we can be sufficiently cautious and assured of treating to the best of our capabilities. 

Thus, the goal of today's meeting is to conduct a thorough haematocrit/biochem workup. Mr. Morrison has been fasting overnight, so we should be able to establish the patient's fasting homeostasis and whether his blood status is cause for concern.

CURRENT MEDICATIONS:

1\. Metaprolol — 100 mg I.V. q.d.  
2\. Heparin — 5000 units I.V. initially; 40,000 I.V. q.h.d. (to maintain until November 6th, 2083)

EXAMINATION:

Cumulative serum biochemistry

| 

Fasting

| 

Ref. Range

| 

Units  
  
---|---|---|---  
  
Na+

K+

Cl-

Bicarb

Gluc

Urea

Creat

Bili

Corr. Ca2+

Phos

Alb

| 

_

_

_

_

_

_

_

_

_

_

_

| 

137-147

3.5-5.0

95-105

25-33

3.0-6.0

2.5-8.0

60-130

2-20

2.25-2.65

1.0-1.4

35-50

| 

mmol/L

mmol/L

mmol/L

mmol/L

mmol/L

mmol/L

umol/L

umol/L

mmol/L

mmol/L

g/L  
  
HbA1c

Homocysteine

| 

_

_

| 

4.0-5.6

4.0-15

| 

%

umol/L  
  
Lipids

LDL

HDL

Trig

| 

_

_

_

| 

80-129

35-60

50-150

| 

mg/dL

mg/dL

mg/dL  
  
Factor I Assay

Fibrinogen

| 

_

| 

1.5-4.0

| 

mg/mL  
  
MMR (IgG)

| 

_

_

_

| 

Index

<=0.90 Neg

0.91-1.09 Equiv

>=1.10 Pos

| 

A positive result indicates the patient has immunization to measles, mumps, and/or ruebella virus. It does not differentiate between active or past infection.  
  
ASSESSMENT

As expected, blood workup revealed highly unprecedented results relative to reference levels. However, in review of reports over the last 14 days and consultations with Mr. Morrison's primary physician, these results are comparable and consistent. Rubella antibodies were robustly detected, excluding an underlying embolism after acute infection. With the exception of LDL, triglycerides, and homocysteine elevation, which are typically observed with hypertension and acute stroke respectively, we may also eliminate elevated fibrinogen activity as a flag for future reference.

I have discussed with Mr. Morrison and his advocates regarding treatment for his dyslipidemia. He will need to consider adjusting his diet in the future to accommodate lower fat and higher fibre intake. It is to my understanding that Mr. Morrison has developed poor eating habits and malnutrition over many years, including his years prior to retirement while working in a high profile/high stress environment in the military. His proxies have assured me that they have been making progress with him in this regard, and will continue to do so moving forward.

STROKE PREVENTION RECOMMENDATIONS

Since Mr. Morrison's swallowing capacity has improved, we are able to address his dyslipidemia conventionally. Previous prognosis for dysphagia was poor, suggesting prolonged intravenous application of his medications, however, Mr. Morrison has made remarkable progress since, so I believe his acute medications for hypertension and atrial fibrillation may also be switched over to oral tablets (warfarin and atorvastatin) for ongoing stroke prophylaxis. I've taken the liberty of prescribing hydralazine given he is still at high risk of heart failure. Thus, I've prescribed his new medications as follows:

1\. Warfarin — 5 mg p.o. q.d. 14 day ramp-up; increase to 10 mg q.d. to maintain after November 10th, 2083  
2\. Metoprolol — 400 mg p.o. q.d.  
3\. Atorvastatin — 20 mg p.o. q.d.  
4\. Hydralazine — 10 mg p.o. q.i.d. 4 day ramp-up; increase to 25 mg q.i.d. for one week; increase to ~50 mg q.i.d, and adjust for lowest effective dosage, to maintain after November 10th, 2083

To summarize, there are no specific results in Mr. Morrison's augmented workup that is case for suspicion. He is a 62 year-old patient with a history of poor nutrition and lifestyle choices that has contributed to his atherosclerotic stroke risk and atrial fibrillation in his older age. His primary focus will be on multidisciplinary inpatient rehabilitation, including physical therapy and trauma counselling to facilitate his recovery.

Dr. Guy Winch

**Notes for the Chapter:**

> My window of free time is closing fast and there's still so much I want to write... ლ(ಠ_ಠ ლ)
> 
> dyslipidemia - abnormal amount of lipids/fats in the blood (including cholesterol).  
Warfarin - another common "blood thinner" or anticoagulant.  
Atorvastatin - a statin drug, helps lower blood cholesterol.  
Hydralazine - vasodilator drug, helps lower blood pressure by relaxing the blood vessels.  
stroke prophylaxis - actions taken to prevent stroke.  
atherosclerosis - vascular disease, in which fatty plaques build up in the arteries, narrowing and weakening the blood vessel walls.


	3. CONSULT 2_09-11-2083

Inpatient Clinic Note

NAME: MORRISON, John F.  
AGE: 62  
DOB: XX-XX-2021  
SEX: M  
DATE OF SERVICE: November 9, 2083  
CONSULTING SERVICES:  
Stroke Neurology  
Physical Therapy & Rehabilitation  
CONSULT REQUESTED BY: XXXXX

*This report is provided in correspondence for the patient's ongoing care. Any blanks represent redacted information. Any discrepancies from the original document should be reported directly to the hospitalist.*

I was asked to conduct a neurological assessment of Mr. Morrison today after his session with physiotherapy. He had fallen during an ambulation practice session on the parallel bars, where he began experiencing convulsions. Staff performed protective first aid on the scene and fortunately, the convulsions endured for less than 3 minutes. Mr. Morrison is currently resting in a bed at the rehab center.

Upon initial observation, NIHSS score is 14/42, an improvement since the patient was last assessed (24/42 on October 16, 2083), mostly due to progress made on his motor skills. Notably, Mr. Morrison is now conversational with only mild inconsistencies in his verbal expression; since beginning inpatient rehabilitation, Mr. Morrison has been diligently attending physiotherapy with fairly steady progress on mobilizing his hemiplegic right side. His core strength has improved enough to allow him to be independent sit to stand. 

MoCA score is 26/30, mostly due to Mr. Morrison's visual impairments and upper motor spasticity. Recall memory was intact, attention was mildly inhibited. During our conversation, Mr. Morrison demonstrated some absence symptoms, where several times throughout my initial assessment he lost focus and became momentarily unresponsive. Prior to this event, Mr. Morrison had no epileptic symptoms of note, however, the degree of ischemic infarction he survives with post-stroke and his history of TBI does suggest he is at moderate risk.

MEDICATIONS  
Warfarin — 5 mg p.o. q.d. 14 day ramp-up; increase to 10 mg q.d. to maintain after November 23rd, 2083  
Metoprolol — 400 mg p.o. q.d.  
Atorvastatin — 20 mg p.o. q.d.  
Hydralazine — 10 mg p.o. q.i.d. 4 day ramp-up; increase to 25 mg q.i.d. for one week; increase to ~50 mg q.i.d, and adjust for lowest effective dosage, to maintain after November 23rd, 2083

EXAMINATION  
fMRI  
BOLD Contrast: __

EEG  
Fp1-O1: __  
F7-O1: __  
T3-O1: __  
T5-O1: __  
F3-O1: __  
C3-O1: __  
P3-O1: __

F8-O2: __  
T4-O2: __  
T6-O2: __  
F4-O2: __  
C4-O2: __  
P4-O2: __

ECG: __  
Time: __

ASSESSMENT  
fMRI: The results of the functional imaging reveals focal areas of ischemia in the left temporal region. Evidence of multiple structural lesions can be identified — a small lesion on the anterior aspect crossing over into the lateral sulcus and diffuse lesions across the inferior sulcus. Sclerotic structures in this region are consistent with the location of previous head trauma in the patient's history.

EEG: Interictal EEG reveals intermittent focal slowing at approximately 4 Hz as well as periodic burst-suppression pattern of activity both in F7-T3 and T3-T5. Results are consistent with affected regions identified through imaging.

Motor assessment: Finger-to-nose is slow going, but normal. No nystagmus indicated. Right upper arm is approximately 2/5 abduction with spasticity. Right leg is 3+/5 hip flexor, 2+/5 dorsiflexion.

RECOMMENDATIONS  
AED therapy - Clonazepam — 0.5 mg t.i.d. (maximum 1.5 mg every 24 hours); to increase to 1 mg q.72.h. to a maximum of 20 mg as required.  
Query surgical lesionectomy or temporal lobe resection — Depending on how the patient responds to medication, I will order a cost-benefit assessment for neurosurgery. I would hope to avoid such an invasive procedure, for which the patient is at higher risk of sustaining life-changing side effects post-surgery, including memory loss. However, the severity of his condition may necessitate intervention. I will follow-up in 3 to 4 weeks to reassess.

Of note, after discussing the treatment plan moving forward, Mr. Morrison has expressed his desire to avoid surgical intervention "at all costs", even if AED therapy is unsuccessful. This would be highly discouraged, as prolonged, uncontrolled epileptic events can predispose him to encephalomalacia and increase his risk of mortality, which was emphasized in our session. Mr. Morrison's executive competency is good, however, there have been inquiries made into his history of untreated PTSD that I suspect may be a factor in Mr. Morrison's decision-making. I would be remiss to neglect the possibility of suicidal ideation, for which Mr. Morrison continues to deny. Mr. Morrison has already been proposed for discharge within the next four weeks and to my knowledge, has been waitlisted for outpatient rehab. He is scheduled for his first appointment with Psychology at the OSI Clinic this week. I will leave a note for Dr. Leigh Manhas in Psychology.

Dr. Yuriy Burstein

**Notes for the Chapter:**

> _toot-toot!_ All aboard the Pain Train. Next stop, Whumpage Station. _toot-toot!_
> 
> NIHSS - National Institutes of Health Stroke Scale. A score of 0 means the patient has no significant post-stroke disabilities.  
MoCA - Montreal Cognitive Assessment. Measures competency and detects levels of cognitive impairment (ie. vision/spatial awareness, memory, attention, etc.)  
TBI - traumatic brain injury  
ischemia - inadequate blood supply.  
infarction - local death of tissue/cells due to inadequate blood supply.  
fMRI - functional magnetic resonance imaging. Basically an MRI where they track blood flow along with brain activity.  
AED - anti-epileptic drugs  
Clonazepam - type of medication used in the treatment of seizure disorder.  
lesionectomy - if the source of seizures is found to originate from lesions in the brain, they are cut/removed in brain surgery.  
temporal lob resection - if a whole section of the brain is found to be the cause of seizures (usually in the temporal lobe), that part of the brain is removed as long as it is in a non-vital region.  
encephalomalacia - loss of Or decreased consistency of brain tissue, ie. softening of the brain due to injury.


	4. OUTPATIENT 1_12-11-2083

Outpatient Clinic Note

NAME: MORRISON, John F.  
AGE: 62  
DOB: XX-XX-2021  
SEX: M  
DATE OF SERVICE: November 12, 2083  
CONSULTING SERVICES: Operational Stress Injury Clinic

*DO NOT ANNOUNCE THE PATIENT*

Copies of this and subsequent reports may not be shared with any external parties, besides the consulting psychologist and designated physicians (See attached). Please contact Dr. Angela Ziegler for a full account of the patient's medical history.

*This report is provided in correspondence for the patient's ongoing care. Any blanks represent redacted information. Any discrepancies from the original document should be reported directly to the hospitalist.*

Mr. Morrison arrived in a wheelchair at the OSI Clinic accompanied by his partner for his first appointment. They arrived on time and without incident. All intake paperwork was handled upfront and the goals and transparency of each stakeholder in these sessions, including myself, were discussed in detail. Due to the nature of psychiatric counseling sessions, the patient and his partner were made aware of the risks of emotional distress and how such reactions were expected and valid. The space, as always, remains non judgmental. Both understood that participation in these sessions was entirely voluntary and that all information shared during sessions would remain confidential.

MEDICATIONS

  1. Warfarin — 5 mg p.o. q.d. 14 day ramp-up; increase to 10 mg q.d. to maintain after November 23rd, 2083

  2. Metoprolol — 400 mg p.o. q.d.

  3. Atorvastatin — 20 mg p.o. q.d.

  4. Hydralazine — 10 mg p.o. q.i.d. 4 day ramp-up; increase to 25 mg q.i.d. for one week; increase to ~50 mg q.i.d, and adjust for lowest effective dosage, to maintain after November 23rd, 2083

  5. Clonazepam — 0.5 mg t.i.d. (maximum 1.5 mg every 24 hours); to increase to 1 mg q.72.h. to a maximum of 20 mg as required.

SOCIAL HISTORY

We began our session with a review of Mr. Morrison's social background.

Mr. Morrison is a 62 year-old caucasian male born in __________ . He is a veteran of public notoriety and had retired from active duty in 2070. His classified status over the last 40+ years of his career limits my ability to inform on his living conditions during this time, however he does report that he is currently living on the recommissioned ___________ military base at ____________ under retirement arrangements. He currently lives with his partner, who is also retired under the same classified status. Of note, his partner reports that prior to their retirement, he and Mr. Morrison had been estranged from each other, as well as friends and family support for several years prior, during which Mr. Morrison acquired poor dietary habits and lacked access to a primary care physician. (See Inpatient transcripts for his most recent course through the hospital).

In his youth, Mr. Morrison grew up as an only child. His family unit comprised of himself, his mother and his father. Both his parents are deceased, having passed soon after his abrupt retirement at age 49. With respect to his family environment growing up, Mr. Morrison notes his father having been a frequent alcoholic. He denies any incidents of abuse incurred by either of his parents, exclaiming that they were "Strict, but fair." Mr. Morrison states that he does not have any connections with either his paternal or maternal relatives.

Mr. Morrison has been openly homosexual for the majority of his life. He reports being in only two intimate relationships in his lifetime, both male partners, the latest being his current partner who identifies as bisexual. The two met each other during basic training in the __________________ program and had maintained their friendship for the majority of their lifetimes, but only recently began to pursue an intimate relationship with each other. They have been intimate partners now for four years. His partner notably has a daughter from a previous marriage, with whom he has strained, but mending communications with. His partner regularly attends family therapy with his daughter and her kin, to which Mr. Morrison often attends as well in support of his partner and his ongoing efforts to reconcile with his family. 

The extent of Mr. Morrison's formal education includes the completion of public secondary schooling (12 years total). After graduation, Mr. Morrison enlisted with the US Armed Forces at the beginning of the Omnic Crisis, where he was subsequently qualified for the _______________________ , a classified augmentation and training program. Mr. Morrison went on to have a long and decorated military career. Having served during the war and through to post-war developments, Mr. Morrison notably survives with numerous chronic physical ailments, including glaucoma, joint contractures and migraines from traumatic injuiries, as well as developing several detrimental behaviors associated with his stressful experiences. Both he and his partner acknowledge that Mr. Morrison's mental health concerns remained largely unreported in his profile before and after his official retirement. His most recent stroke event has been the primary factor in bringing his trauma to the forefront of his friends' and family's concerns over its effects on his recovery and health moving forward.

SESSION NOTES

(See dictation for full session recording.)

After reviewing his social history, I opened the discussion to Mr. Morrison for his thoughts and feelings so far, especially in regards to concerns of behavior changes, depression or self-harm highlighted by my colleagues as well as Mr. Morrison's close friends and family. 

Mr. Morrison stated that he did not particularly feel he was "depressed", although he mentioned experiencing sudden moments of shame and guilt for past events he was a part of, for which he would not elaborate further. With respect to behavior changes, he acknowledged that friends have pointed out his reckless and impulsive behaviors as a mercenary in his later years moreso than in his youth, although he attributed this behavior to old age rather than a lapse in judgement. He also mentioned persistent feelings of isolation from his family and friends, despite how prominent their presence has been in his post-retirement life, and especially after his stroke. He expressed frustration with such sentiments, feeling that he is often misunderstood, victimized, and invalidated based on his history and acquired disabilities, despite how much experience and capabilities he still has to offer. He believes in his ability to recover his IADLs and wishes very strongly to keep involved in his friends' and family's lives as he has been in the past. 

When asked about whether he maintains any hobbies or interests after his retirement, Mr. Morrison noted golfing, cooking, and bush craft camping, all activities he used to enjoy during his free time, but has not partaken in for many years since his military career subsumed the majority of his time and attention. He now no longer feels motivated enough to pick up new hobbies due to his visual impairments and due to a disbelief in how these activities could be enjoyable for him now in his older age. When asked for an approximate timeline of when his lack of motivation and emotional symptoms began to interfere with his daily activities, he estimated approximately somewhere between five to ten years post-war (during his mid to late 30's).

At this point, Mr. Morrison's partner expressed his feelings in contrast. Both men are similar in age, Mr. Morrison's partner himself suffers from operative stress and a chronic condition acquired from their shared history of military augmentations, thus he reasoned that Mr. Morrison is struggling to come to terms with the expected impairments that come with age and the chronic stress they both sustained by nature of their occupations. He believes this to be the cause of Mr. Morrrison's failure to thrive, exacerbated by his rejection of the care and support he needs from their friends and family, including his own partner.

There were some argumentive words passed between the two men, to which I promoted composure and empathy. I emphasized the need for open understanding and affirmation of each other's experiences. The goal of our sessions is, as always, to provide a safe and supportive space for Mr. Morrrison and those closest to him whom he is welcome bring along, irrespective of differing moral grounds and opinions. 

The session concluded on amicable terms and without incident. I provided my contact information to Mr. Morrison, encouraging him to speak with or message me for any reasons between now and his next appointment.

SYMPTOMS OBSERVED/REPORTED DURING SESSION

  * Avoidance - Mr. Morrrison demonstrated reluctance to speak openly about significant events in his past that are tied to his recurring feelings of guilt.

  * Behavioral changes - Mr. Morrrison admits to engaging in reckless activities he otherwise would not have done prior to his retirement from the military.

  * Persistent memories of traumatic events - Although he did not elaborate, Mr. Morrison did mention reliving past events during unexpected moments of his day which caused intense feelings of guilt and anxiety. 

  * Loss of motivation and interest - Mr. Morrrison reported his loss of enjoyment in previous leisure activities. This is compounded by the limitations of his acquired impairments over the years. Mr. Morrrison seems to have no intentions of accessing disability services, which could help provide him with the means to participate in these activities.

  * Restlessness - Mr. Morrrison demonstrated restless fidgeting throughout the session, primarily rubbing his knees and wrists when agitated.

DIAGNOSIS

  1. PTSD

  2. Depression

  3. Query suicidal ideation (see below)

INTERVENTION PLAN

  1. CBT — subsequent sessions will be focused on identifying persistent, negative, false perceptions and coaching cognitive skills to promote positive mindfulness and routine task-setting.

  2. Fluoxetine — 20 mg p.o. q.d. 14 to 21 day ramp-up; increase by increments 0.5 mg weekly as tolerated, to adjust for sufficient clinical improvement in affect to a maximum of 60 mg. I've prescribed fluoxetine for the purpose of treating Mr. Morrrison's depression, however, the medication may have secondary treatment effects. Post-stroke imaging shows accelerated neuroregeneration, attributed to his physical augmentations. This extraordinary ability appears to have been both beneficial and detrimental to his recovery, leaving epileptiform scars, but suggesting an abrupt critical window for neural plasticity, which is shortened beyond what is normally found in post-stroke neural environments. Antidepressants, such as fluoxetine, are known to reopen the critical window, thus I am optimistic in the benefits this may have in improving his prognosis for surgery.

FUTURE TREATMENT/FOLLOW-UP

As the goal of this first session was primarily to establish a foundation of trust and confidence, I withheld inquiries on Mr. Morrrison's alleged changes to his emergency medical response status (DNR 2 from a full code; see discharge report). Such sudden changes to his notations is cause for concern, especially when considering how he has attested to reckless behavior in more recent years. He is currently under supervision by his loved ones and extended care staff, who are aware of his risk of suicide. This is something I hope Mr. Morrison will be comfortable openly discussing in future sessions to best facilitate his needs through CBT.

I have encouraged Mr. Morrison to continue having friends and/or family members accompany him to the first few sessions if this is a more comfortable arrangement for him. However, I have recommended future independent sessions to be the main focus, where he has the opportunity to speak his thoughts and engage in constructive, nonjudgmental discourse with myself as a trusted confidant. I look forward to seeing Mr. Morrison at our next session.

Dr. Leigh Manhas

**Notes for the Chapter:**

> IADL - instrumental activities of daily living; activities not fundamental to everyday functioning, but allow the individual to be independent within their community. 
> 
> CBT - cognitive behavioral therapy; a kind of "talk therapy" commonly used in counselling by psychologists where negative, false ideas of the patient are challenged by the therapist by task assignments. If I remember correctly, it is based on the model that theorizes how thoughts affect behavior and vice versa, thus changing behavior first can eventually lead to changes in your thought process. Or, I'm just BS'ing gibberish and should probably look this up properly, so please don't quote me on this.
> 
> fluoxetine - aka Prozac, a type of antidepressant medication, often paired with CBT.


	5. OUTPATIENT 2_08-12-2083

FILENAME: PAC43_08-12-2083_FILE4

FILE LOCATION: ftp:\\\XXX.XXX.XXX.X\Databases\OSIC\Manhas\CSH_00\MRN_2054076

DATE: 08-12-2083 14:32

Length: 00:56:32

[00:00:03]

Manhas: Is there anything in particular you would like to talk about today?

JM: Well, you're the one who asked me to meet you here instead of your office. What do you want me to say?

Manhas: John, you are always free to let me know at any time if there's anything that makes you uncomfortable. It's not a problem for us to move on to something else. I'm here to work with you, not against you, and never against your will.

JM: No, no. I apologize. You're right. I'm just— don't mind me. 

Manhas: Are you sure? We can always move back to my office if that's more comfortable for you. We're only here because the medications provided by the sexual health center aren't allowed to be taken out of the clinic without documentation.

JM: I'm sure. I'm sorry. I'm just, I guess, feeling reluctant to talk about this. It's not normal to talk about your sex life so explicitly with anyone other than your partner, you know?

[00:00:55]

Manhas: You are absolutely right. I understand it's not the easiest thing to talk in the open about something so private, but it is, I assure you, not any less deserving of concern from a health and medical perspective. Intimacy and intercourse are natural to human behavior and very much associated with our physical and emotional well being. We otherwise wouldn't have an entire department dedicated to sexual health in our hospitals.

JM: Of course. 

Manhas: So are there any concerns you'd like to discuss, John? Anything I can help you with?

JM: You can call me Jack.

Manhas: For sure, Jack. Then please, call me Leigh.

JM: Of course. Dr. Leigh.

[Laughter]

JM: I'm not sure where to start. 

Manhas: How about your relationship with Gabriel? You mentioned last session some frustration there.

JM: Not sure frustration is the right word to describe the feeling. Complicated, self-destructive, confusing. Anything dysfunctional would suffice.

[00:04:34]

Manhas: I see. I understand you've known each other for a long time, and that you both have been significant in each other's lives. Why did you both decide to start a relationship now after so many years? What changed?

[Extended silence, ambient sounds]

[00:09:12]

JM: It was a mutual decision. We're both only getting older and I guess the lonliness was setting in. 

JM: I love him. I always have, even when I didn't know it and even when we weren't together. No else has understood me, or stayed in my corner, or stood up to my bullshit, the way he does. Maybe Vincent, but not in the same way. Vincent wouldn't have pushed my buttons. He was too good for me.

Manhas: Do you think you don't deserve some good in your life?

JM: Are you implying that Gabriel might not be good for me? Sure he makes mistakes like any of us do. But he's a good man.

Manhas: I'm certain he is. Let me reword this. Why is it that you feel that something could be 'too good' for you? Do you feel unworthy of a loving, intimate, and reciprocal relationship? 

JM: I never said we lacked intimacy, only that I've been nervous about. Performing. Ever since my stroke, I haven't felt— I haven't felt the same. It's ruined many nights we've had together already.

Manhas: Mhm. Just a reminder, Jack, that you are deflecting a bit. But as we both know, this is something that takes time, something for when you are ready to talk about it. And I want you know, you are worthy of love, of companionship. The fact that you care so much for your friends and family is admirable. It speaks to the strength of your character and deserves to be reciprocated.

[Extended silence, ambient sounds]

JM: Thank you.

[Extended silence, paper shuffling]

[00:18:44]

Manhas: Would you say that you've been having less of a physical response to sex? Or have you just had no interest in sex with your partner of late?

JM: Both I think. He's been the one initiating lately. And I feel guilty for not responding like he does. I don't want him to think I don't feel the same way.

Manhas: It's nothing to be ashamed of, I'm glad you're telling me this. It's actually quite common for individuals to experience some sexual dysfunction or suppressed libido post-stroke. Any injury the brain sustains can disrupt connections involved with our emotions, arousal, memory, due to changes in the chemical environment. 

JM: That makes sense.

Manhas: Indeed. I think it would be wise for you to discuss this with Gabriel. You still have the option of using sildenafil, which I am giving you today, although I would advise you use it sparingly given your cardiovascular risks. We want to keep your health in check, especially since you have been doing well with controlling your blood pressure. You've also been tolerating the fluoxetine so far, and we're hoping it will continue to help your recovery. Your surgery is coming up as well, so I recommend erring on the side of caution.

JM: Right, I'll try to remember that. But, I've told you before, I'm still not comfortable going ahead with this surgery. If I'm doing so well, I don't think I need it.

Manhas: Of course. I've consulted with Dr. Burstein about your concerns. We have been very happy to see the progress you've made, for sure. However, I also think it's important for us to acknowledge that the severity of injuries your brain has sustained over the years has put you at high risk of neurodegenerative decline down the road. We all have our limits, and it's okay to accept help when you need it. The surgery is meant to help you live the best life you can have, pain-free and stress-free.

JM: Hm. Everyone doesn't understand, it's not that bad. I'm already used to migraines and this shouldn't be any different. I've experienced much worse things in my life. I was a goddamn soldier. Pain is just a reality of my life. It's just the way things are. I can take it. 

[00:31:29]

Manhas: Do you think you are keeping your family and friends happy by continuing to let yourself suffer? Is it necessary to put yourself through pain when we have treatments that can help ease your condition? It doesn't matter how long you've put up with it, pain is not the normal. Whether you think you can 'take it' or not, if being in pain still makes you suffer and in turn, hurts those you care about, then the pain is affecting your life negatively. 

[Extended silence, ambient sounds]

JM: Hm.

Manhas: Talk with Gabriel. You both have been through a lot together and I know your health has been a sore topic between the two of you. You have options Jack, no one is forcing you to take the surgery. But, I only hope you will remember that you deserve to live your life without pain or suffering. You are a good man, too.

[Extended silence, ambient sounds]

[00:45:27]

JM: Yes. I'll talk to Gabriel.

Manhas: Good. That's good.

[_chair moving, paper shuffling_]

Manhas: All right. Let me go fill in the prescription for you. I'll be right back.

[_footsteps, door closing_]

[_Extended silence_]

[00:49:51]

JM: [_mumbling_] Even if I talk, he won't listen [_mumbling_]

[_Extended silence, door opening_]

[00:51:36]

Manhas: Here we are.

JM: Thank you, Dr. Manhas.

Manhas: You're very welcome, Jack. Now, just a reminder, I'd like you to use these sparingly. One tablet, about twenty minutes before intercourse. You shouldn't be taking more than twice per week, to be on the safe side.

JM: Oh, I'm sure that won't be a problem. I'm spry, but not that spry anymore. When you get to be my age, your back side can't take as much of a beating as it used to.

[_Laughter_]

Manhas: All right. Is that all we have to talk about today? Any other concerns, questions?

JM: No, none I can think of right now.

Manhas: All right, then. Well, it's always a pleasure to see you, Jack.

JM: You as well, Dr. Manhas. Thank you.

[00:56:32]

[_End of transcript_]

**Notes for the Chapter:**

> sildenafil - drug used to treat erectile dysfunction in men, aka Viagra. I think that's self-explanatory.


	6. CONSULT 3_27-12-2083

Preoperative Consult

*ACCESS GRANTED*

NAME: John F. Morrison  
AGE: 62  
DOB: 07-01-2021  
SEX: M  
DATE OF SERVICE: December 27, 2083  
CONSULTING SERVICES:  
Neurosurgery  
Cybernetics  
CONSULT REQUESTED BY:  
Dr. Angela Ziegler

LOCATION: Watchpoint Veterans Hospital - Extended Care

COMORBIDITIES

  1. Lifetime smoker of at least 40+ pack years (cessation reported October 20, 2083)
  2. COPD and emphysema
  3. Alcohol use disorder
  4. Glaucoma — visual impairments more distinct in the right eye, but legally blind
  5. Migraines with aura
  6. Seizure Disorder
  7. Hypertension
  8. Depression
  9. MCA Stroke with embolic showers (October 16, 2083)
  10. Heart failure

MEDICATIONS

  1. Warfarin — 10 mg p.o. q.d.
  2. Metoprolol — 400 mg p.o. q.d.
  3. Atorvastatin — 20 mg p.o. q.d.
  4. Hydralazine — 50 mg q.i.d.
  5. Clonazepam — 20 mg q.72.h.
  6. Fluoxetine — 60 mg q.d. - to maintain for a maximum of 12 weeks post-surgery scheduled for December 31, 2083 (see below).

CHARTING NOTES

(See dictation for full session recording.)

I met Jack today at the Watchpoint Veteran's Extended Care facility for his preoperative checkup. This will be his last appointment with me before his neurosurgery for a left temporal lesionectomy on December 31, 2083. He arrived for his appointment ambulating independently, while using his wheelchair as a walking aid. He has a slight hemiparetic gait, favoring the right side, however, his balance confidence has improved since his last appointment four weeks ago. Upper arm spasticity has been reduced and displays greater flexibility with increased passive and active ROM. I detect minimal speech disturbances during normal conversation, but his speech remains essentially slow and can be occasionally effortful.

Cessation of cigarette smoking occurred at the time of Jack's stroke in October, thus a minimum of 8 weeks has elapsed since the initial event, which is ideal for his preoperative prognosis. He has been on NRT with nicotine patch and reports not relapse in smoking behavior. Blood pressure was 142/94 mmHg upon arrival, 138/84 mmHg on second reading, which is high-normal with respect to his blood pressure journal. Triceps tendon and quadriceps reflex is normal.

Notably, Jack reports having had a fainting incident of unknown length outside of visitation hours about three days ago that was undocumented by staff. He mentions "waking up slow", feeling generally unwell as if he was "run over by a Bastion assault-cannon", and was paralyzed for a period of time after regaining consciousness. Without monitoring of the event at the time it occured, I cannot comment on the character of this epileptic event, however, the fact that he has had an incident now despite being on AED (clonazepam) further necessitates surgical intervention to improve his prognosis. (See below for neurology assessment).

In review of Jack's medical history, we discussed his current outpatient therapies and progress in his treatment course through the Extended Care Rehabilitation program:

  1. Physiotherapy - Reports from the physiotherapist state that his physical strength and endurance has improved over the course of intensive exercise rehabilitation. The program included PNF stretching for muscle contractures, walking stability, balance confidence exercises, and general strength and conditioning focussed on core stability and the lower extremities.
  2. Speech Therapy - His non-fluent aphasia has been resolved for the most part and swallowing capacity has recovered. Jack is now on a solid food diet. Residual characteristics in his speech remain, such as slight slowness in his pronunciation and word-finding.
  3. Nutritionist - Jack has seen a nutritionist to develop a suitable nutritional plan for reducing his blood pressure, controlling his cholesterol and gaining healthy weight. His electrolyte status has also been maintained to his individual baselines. His body weight remains lower than expected (BMI 18.7) for an adult of his size, but has improved since his admission to extended care and is within low-normal health expectations.
  4. Neurology - According to the most recent report from Dr. Burstein, AED has had notable therapeutic effects in reducing the severity of Jack's absence episodes. However, as noted above, Jack has had at least one undocumented incident while on clonazepam, which is not an ideal long-term treatment given the risk of developing tolerance to the anticonvulsant effects. Recent T2-weighted imaging reveals some atrophy in the left mesial aspect of the temporal cortex, consistent with the appearance of neocortical gliosis and EEG focal slowing. Contrast has marginally reduced in the anterior superior aspect corresponding to Broca's area above the left lateral sulcus.
  5. Psychology - Jack has been attending sessions with Dr. Manhas at the OSI Clinic for his PTSD. I have been aware of Jack's physical and mental risk factors for many years, and it should be noted that this is the first time that Jack has consented to seeking help which is commendable progress in itself. The content of their sessions remains under strict confidentiality, thus as Jack's primary physician of 20+ years, I am obliged to maintain his privacy and remain unbiased in my concern for his well-being. Dr. Manhas has generously provided feedback in regards to his progress, stating that Jack has been cooperative and making sure steps to improve his quality of life. Jack has been taking fluoxetine primarily to treat his depression. Although antidepressants such as fluoxetine are known to reduce fatigue early in the ramp-up period with a delayed effect on serotonin levels and affect, which increases the risk of acting on suicidal thoughts, Jack reports having no such symptoms. I am suspect to believe his claims, given Jack's history of presumptive suicidal ideation and confirmed PTSD, but regardless, he remains under strict supervision by his friends and loved ones and I trust he has sufficient social support in his pre and post-surgery management.

CLINICAL RISK FACTORS

  1. Hx of stroke
  2. Hx of heart failure
  3. Hx of ongoing seizures

PREOPERATIVE OPTIMIZATION

Overall, I am pleased to see that a holistic consensus on Jack's medical care has been met. He was cleared by the anesthesiologist last week during his preoperative assessment with them. Jack has been diligent in improving his post-stroke physical endurance and reducing his modifiable risk factors. His nutritional status and electrolytes has also improved, however, this will still need to be monitored since he is still regaining healthy body weight. I don't expect this to be a problem for his surgery as he is not anemic and is within the normal BMI range. I will be making some preoperative changes to his medications per the following:

  1. Rivaroxaban — 15 mg p.o. b.i.d — to replace warfarin pre and post-op, indefinitely. Transition to NOAC drug for anticoagulation therapy should reduce Jack's hemorrhagic risk and the need for INR monitoring in the long-term.
  2. Furosemide — 40 mg p.o. b.i.d — given his risk of heart failure and borderline blood pressure status, a diuretic in combination with his current therapies is recommended.

As the lead neurosurgeon and a longtime friend, I wish Jack all the best for his surgery and recovery. Jack maintains his anxiety over the surgery, but I have reassured him to the best of my ability and he has given his consent to proceed. He has suffered a great deal in his lifetime, and I will endeavour to make sure this procedure will finally bring him much needed relief from his physical symptoms.

Dr. Angela Ziegler

**Notes for the Chapter:**

> NRT - nicotine replacement therapy  
rivaroxaban - another anticoagulant drug, works different from warfarin (called NOAC's, non vitamin K oral anticoagulants) and is generally considered a safer, but more expensive option (at least right now).  
INR - International Normalized Ratio, basically a comparison test (along with some other tests) to make sure the patient's blood clotting ability stays normal while taking anticoagulant medication (typically warfarin).  
furosemide - diuretic drug that makes you urinate more electrolytes (thus, increasing water loss). Sounds bad for hydration, but it is beneficial for patients with heart/kidney failure to prevent too much fluid build-up.


	7. CODE YELLOW_Location: VH-EC

[Announcement]

_<Code yellow, stage two. All staff level 12, report to search coordinator at nursing station 3, Extended Care. Code yellow, stage two. All staff level 12, report to search coordinator at nursing station 3, Extended Care.>_

[Voicemail, recipients: All Staff, Extended Care Unit]

<Code yellow, stage two. Patient from room 1228 is missing from the facility. Patient is a 62-year old caucasian male, height 6' 9" (205 cm), weight 174 lbs (79 kg). He has short, white hair, blue eyes, notable scars bisecting the face and chin. Patient is blind and ambulatory, but has significant walking disability. He is high risk for epileptic seizures.

Patient responds to the name "Jack". A reminder to please respect patient's confidentiality and identity at all times. If found, please stay with the patient and report to the search coordinator immediately.>

**Notes for the Chapter:**

> Here comes the drama. Yell at me in the comments.


	8. December 31, 2083: New Year's Eve

**Notes for the Chapter:**

> The concept of this chapter was written several years ago, and now here we are. Hope you enjoy :)
> 
> PS: Jack is an unreliable narrator.

0930: Nurse comes in, checks the chart, checks his vitals. _"Good morning, Jack. Hope you're hungry. Today's breakfast looks delicious_!" Smiles.

0935: Take meds.

0945: Angela arrives, checks the chart, checks his vitals. A cool palm on his forehead. _"Just checking in on my most favorite stubborn patient."_ She smiles.

0948: Eat enough to satisfy his quota, leave the rest. Get dressed (_do it yourself. Don't ask for the nurse_).

0955: Orderly arrives, checks his wheelchair, takes the handles, positions the seat. "_Morning, Jack. Ready to head down to physio?"_ Takes his arm gingerly, like glass. Smiles.

1150: Lena and Winston and the rest arrive. Ana brings tea, Reinhardt and Torbjorn and his family bring a smorgasbord. Gabriel brings himself and cookies. Lunch in the cafeteria. Everyone is smiling (_Gabe doesn't. He promised not to_).

1630: Family therapy. (_Hold his hand_).

1744: Gabe drives them home. Take sildenafil.

1823: _"We're arguing over nothing"_. Quiet dinner.

2027: Back to the hospital. Nurse comes in, checks the chart, checks his vitals. _"Your last meds for the day are on the table. Remember, you'll need to fast before surgery tomorrow, so water or juice only. How was your day today?"_

Smiles, smiles, and smiles.

2239:

2257:

2258:

2259:

2300: Leave.

* * *

It's cold outside. It was a brief observation, harmlessly slipped through his mind. He probably should have given it more thought, but instead he acknowledged, compartmentalized, and kept walking.

Up until the moment the night air scraped his skin, everything he remembered about the hospital and its various junctures from memories of a different time hadn't changed, much to Jack's benefit. The stairwell access still had a faulty latch; the railing on ground floor still bore imprints from Gabriel's crushing grip on his way to Gerard's room many years ago; the halls were a chaotic flurry of movement from emergency admissions and triage. No one spared a glance for another wandering body, limping through the lobby unattended.

It was painfully easy to leave, while lost in a crowd of overworked staff and distressed visitors. Easier than overcoming the shame and the guilt he felt in the act. Jack was supposed to be a soldier and good soldiers don't run from their problems like beaten dogs. They don't reject the advice soundly given by their more capable peers. They don't carry useless sidearms, loaded with only a single bullet in the chamber. They don't let their personal feelings get in the way of surgeries that needed to be done. 

Jack was a soldier, but ever since his stroke — or perhaps long before his stroke ever happened— he wasn't so sure he could keep being a _good_ one. 

_(Jack? Jack. Look at me. What's wrong?... Fuck, he's having a stroke, call the ambulance...)_

Gabriel thought he could be, but his confidence only bolstered his shame for all his failings. If he laid bare every childish fear that gripped him and the growing sense of loss, would Gabe understand? Without fail, their conversations of late drifted back to the inevitable surgery, and the fear would come creeping up his neck, paralyze his jaw, heave spiteful words from his throat. Disagreements became angry accusations, then curses spat at each other, a heavy cloud of frustration dispersed into their orbit with every breath. Then Jack's opportunity to confess his flaws would pass and Gabriel would look at him with disappointment in his eyes, none the wiser that his expectations of the man he knew better than himself was all a lie. All those years spent dreaming, yearning, pushing themselves to the limits of possibility, honing their skills, taking risks for the greater good — all for nothing, because Jack, in the end, was nothing but a coward.

At least Gabe didn't hide his disappointment like everyone else with their somber smiles (unseen, but he could feel the fallacy of them on his skin, like microwaves burning through his flesh). At least Jack could always count on Gabe to be truthful with him.

_(Do you think you don't deserve some good in your life?)_

The wall Jack had been following abruptly ended in a dense patch of bushes and he unsteadily limped forward without any handholds. He walked until the scrape of his shoes on the icy pavement and the sudden drop off beneath his soles told him he'd reached the end of the sidewalk. The drone of revving hovercars echoed in the distance. Should he cross? The intersection around the hospital was sparse this time of night on New Year's Eve, no traffic to muddle his sense of direction. _Be brave, you damn coward._ Jack felt specks of frost whip through his thin night clothes as he took a step forward onto the street.

Without the wall the support him, his progress was slow-going. The cold was starting to seep into his cramped muscles, but just like all his physical discomforts, it was acknowledged and quickly compartmentalized. He kept walking.

_(There are some expected side effects to the surgery that you should be aware of...)_

Walking was easy, because Jack had a weakness now, more crippling than any physical disability could ever do to him. If Gabriel, if anyone ever realized the pathetic fears that gripped his mind, Gabe would surely scoff at how paper thin his reasoning was. _Suck it up, soldier, _he would say._ You'll live to fight another day. That's all that matters in the end to people like us._

Home was 5.3 miles south southeast. 

Jack would rather be dead and done with than alive long enough to be a burden on the people he cared most about. And yet, these last two months had easily shaken his resolve. He was weak. He owed Gabe the truth.

He couldn't feel his right side anymore. Half deadweight, half crutch. If he stopped here, he wouldn't be getting up again. He kept walking.

Home was 5.2 kilometers away. 

* * *

Gabe got the call just as the city finished it's ten-second countdown to midnight. Soon enough, everyone would be celebrating new beginnings in every timezone as the countdowns continued, the world ever turning onwards on its axis.

Gabriel stared at the holoscreen. His brain couldn't seem to process what was being said to him. Jack was missing? He'd just seen his partner less than two hours ago. Before that, they had had dinner together. And before that, the argument. _This is my fault_, the mantra echoed restlessly in his skull and wouldn't leave him as he threw his clothes back on and took off from the driveway. As he drove down the street, he called Ana. The former sniper kept her composure much better than Gabe had at the news, which only frustrated him further.

Yes, he needed to stay calm. No, he did not know where Jack would have gone.

His mind, like a well-oiled machine, started shuffling through scenarios, calculating routes one by one. Jack couldn't have gotten far in his condition. The question was, what the hell was he thinking?

Gabriel took the next corner a little too fast and the hovercar swerved into oncoming traffic before he quickly corrected it's course. Indignant car horns blared into the distance as he sped off. Gabe turned on the wipers as icy flakes streaked past the window outside and started collecting on the windshield. His mind wandered.

Four years ago, Jack was the one who asked first. With Talon's remains exposed and dismantled under international security and the people's hopes restored in the new Overwatch, there wasn't much left in a peaceful world for super soldiers like themselves. At least they could face whatever came next together. Those were Jack's words back then. 

Gabe never questioned him. A relationship made sense, for old soldiers like them, who without the stench of war on their noses would probably die of loneliness first. The least they could do was try to keep each other's demons at bay, futile as it might be. Unquestionably, there was no one else Gabe trusted his back to more than that blond boy scout with the bloody fists from basic, or the old hard-ass vigilante who went along with his batshit crazy, double-crossing gambit. Intimacy wouldn't change who they were to each other, their friendship or their partnership. Like with every hurdle in Gabriel's life, he persevered, adapted, and never wavered.

But then Jack had a stroke. And for the first time in a long time, Gabe felt lost.

_(Recovery will not be easy, but we're going to do the best we can...)_

Gabe wiped the cold sweat from his brow and glued his eyes to the road. Despite his attempts to clear his head, his thoughts continued to spiral over the whereabouts of his wayward partner, Jack's motivations, the hurt, the anger and frustration over his stubbornness, a sudden _dread_ that Jack had given in to his depression — when he caught something, _someone_, out of the corner of his eye and slammed his foot on the brakes.

* * *

Jack told himself he only needed a moment. He would rest for a few minutes and be back on his way in no time. But then, he'd felt his way to the snow-covered front steps of a building and slowly sank to the concrete with every muscle screaming at him the whole way down. Then the pain, the numbness settled into his bones, as if his joints had rusted in place.

_Just a few minutes_, he tried to convince his frozen limbs. A few minutes is all it took for him to close his eyes and drift.

* * *

_Jack. Jack!_

_"Jack, wake up!"_

Jack feels himself slowly brought to consciousness by a hand roughly shaking his shoulder. Where is he? _It's cold outside. _Right, he was taking a break. There are hands on his face now, brushing snow off his hair, his clothes. A blanket— no, a jacket is suddenly thrown over him, already warmed by the body it came from. It smells familiar.

"Goddamnit, Jack. What the hell were you thinking?"

Gabriel. How did he get here? Jack did his best to unfurl himself as his brain slowly switched itself back on, one function at a time.

Gabriel meanwhile, had pulled out is phone one-handed and sent a hurried message to Ana, his other hand still locked tightly to Jack's shoulder, keeping him steady. When he glances back at Jack, the old soldier had closed his eyes again.

Gabriel shakes him again. "Jack. Stay awake, you stubborn, old gringo." 

Reflexively, Jack opens his eyes with a frown. "I thought we were past the name-calling," he mutters. Jack turns his head in Gabe's direction, his unseeing, pin-prick gaze slightly off target. "You haven't called me that in years."

With a heavy sigh, Gabriel clears off the snow next to Jack on the concrete then sits himself down. He keeps one arm clamped around Jack's shoulders, not really trusting the man to not get up and leave again, injured or not. Jack doesn't protest, but he shifts, restlessly, like a child who'd been reprimanded for bad behaviour. He technically should be for the stunt he pulled off tonight. If Gabriel didn't do it, then Ana or Angela certainly would. 

But, when Jack couldn't sit still, it was always because there was something nagging at him, a wrong that needed to be corrected, compelling him to act. It was in Jack's nature to check all his bases, say what needed to be said; do what needed to be done. Sometimes, Gabe thinks Jack would have been better off without that kind of unabashed honesty. The world spared no sympathy for people like him. _And look where he is now_.

Gabriel grits his teeth. "You are the biggest, fucking idiot I've ever known. Whatever reason you had for walking out on the hospital and wandering outside in nothing but your jammies? _It's not worth it."_

Beneath his arm, Jack stops fidgeting. There's a prolonged stillness between them before Jack responds. "This was a mistake," he grumbles.

"A mistake?" Gabriel feels blood start rushing through his ears. "That's what you call nearly killing yourself with alcohol, writing a DNR in your own goddamn will, and carrying that stupid pistol around. Yeah, you know which one I'm talking about." Jack shoots him a pissed off snarl, which he pointedly returns with his own disapproving glower.

"You're an asshole. I don't know why I—" Jack abruptly cuts himself off with a grunt. His face falls. Gabe waits for him to finish (he usually does. Spite or the urge to retaliate win out more often than not). But, the silence stretches and Jack is oddly quiet. There's a distant look on his face, the abnormal stiffness of the right side of his mouth accentuated by the diffuse lamplight reflecting off the snow.

Gabriel feels the unease grow again, an angry tumour in his chest. "Spit it out, Jack. You want to say something, I know it."

"You won't listen."

"I'm listening now."

"Then you won't understand."

"How can I ever understand when you don't tell me what's wrong?"

"You think I haven't tried?"

"No, you didn't. If you did, you and I wouldn't be sitting here trying to figure out why you keep hesitating to _fix_ this. What the hell are we even doing anymore? What do you want from me, Jack?"

"_I don't want anything_. Fuck, Gabe I don't..." Jack trails off again.

"You don't what? What is it that you want?"

"I _don't_ want!" Jack raises his voice and chokes on his swelling anger. He coughs, roughly shrugs Gabriel's arm off in frustration. "The doctor said. I might..." 

Gabriel watches as Jack's anger deflates, all at once, his own irritation dissolving with it when Jack's voice trembled ever so slightly. For the first time, he realizes that something is very wrong. 

"Jack?" he asks, warily. Jack's shoulders start to shake, so Gabe brings his arms back around him.

Jack coughs, immeasurable sadness clogging his throat. "_I don't want—_" he chokes out, but the words fall through as Gabe rubs his back, his arm, soothingly. "The doctor said. Memory. Side effects. I—"

"I don't want to forget any of it."

Gabriel feels his heart drop.

"_I don't want to forget you._"

The realization hits him in waves, every impact stabbing deeper than the last. 

"I'm sorry," Jack murmurs and hangs his head, but Gabe already caught the tracks running down his face. He was suddenly reminded of all the years spent as not just friends, but _best_ friends. Best friends squabbled as often as they slept in the same tent, or shared the same clothes. But, between the years of companionship, the heated disagreements and the grievances, there was always the hint of underlying contentment. It was the gravity that pulled them back together— it was joy for knowing they had the kind of closeness that you only find once in a lifetime. It wasn't perfect. But it was _them_. It only took Gabriel nearly five decades to finally realize it.

_"I don't want to forget you," _he rasps again, because the levee was broken now and the words came easy.

Now, Gabe finally understands, and the connections spread inside him like wildfire. All this time, what he thought were feelings of anger and stubbornness plaguing them both since Jack's stroke— was actually _fear_. The steadfast man Gabe knew, the man who wouldn't hesitate to jump into a pit of enemies, throw himself between a bullet and the defenseless— that man was afraid for the first time. Jack was afraid of losing him. It was fear for knowing he had someone that he was reluctant to let go of, let them disappear from his life. Someone who makes saying goodbye so hard, when goodbye ever comes. They were unacceptable feelings for soldiers living on borrowed time. Gabriel couldn't care less.

Because he feels the exact same way.

He was lucky for the tears now streaming down the creases in his cheeks, the bitter taste of salt at the corners of his mouth. Jack loves him and no one, not even the man's own failing memory, or Jack's misguided sense of duty, could take that away from him.

"I'm sorry," Gabriel breaths and grips Jack harder than he could ever allow himself with anyone else. He presses his face to Jack's temple, thin hairs brushing his nose. "I'm so sorry. I'll stay tonight, I promise. I'll stay."

"Gabe. I'm s-s..."

"I know, Jack." Gabe breaths and Jack settles, focuses on those resonant sounds in his partner's chest like crashing waves, or ripples through the tall fields in Indiana. In and out. Back and forth. 

"At ease, soldier. At ease."

Jack can't speak at all by this point, but Gabe reads the three words on his lips. He whispers them back. Gabriel holds his partner, holds their cracked pieces together while the snow falls, softening the distant emergency siren on its way to pick them up from where they lost their way.

**Notes for the Chapter:**

> Thank you to everyone who stuck with this one to the end! It wasn't the easiest read for all the medical jargon and the epistolary format in general, but it was a fun side project to procrastinate on nonetheless. ٩(ˊᗜˋ*)و
> 
> Thanks as well to everyone who shared their thoughts in the comments! It was fascinating to see how people recognized the real world elements of the story and related in some ways to the experiences Jack was going through. There are a lot more issues that Jack has that haven't been resolved here, but I felt like easing his fears was what he really needed to make that first step to real recovery.
> 
> Hope you all are doing well. Stay inside, stay safe, stay positive ♥
> 
> PS: Epilogue? ٩( ᐛ )و


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